DISCLOSURES LEARNING OBJECTIVES. 21st Century Strategies: Transgender Hormone Care. Patient/PCP. Medical model

Transcription

1 21st Century Strategies: Transgender Hormone Care DISCLOSURES Joshua Safer, MD Center for Transgender Medicine and Surgery No conflicts of interest Just about the entire talk is "off label" LEARNING OBJECTIVES 1. Articulate the change in landscape for transgender medical care 2. Outline transgender hormone strategies 3. Consider transgender hormone monitoring strategies Endocrine Society Clinical Practice Guideline New Pediatric/Adolescent Recommendations: Recognition that there may be compelling reasons to start cross-sex hormones prior to age 16 years in some GD/Gender Incongruent adolescents Potential risks to bone health with prolonged hypogonadism Potential risks to mental health if pubertal development is markedly out of sync with peers Pubertal induction Lab surveillance Endocrine Society Clinical Practice Guideline New Adult Recommendations: Enhanced communication by replacing older language. Removal of the obligation that the transgender diagnosis be made by a mental health provider in favor of: The suggestion that the diagnosis be made by a knowledgeable clinician and A statement of the expertise required among treating clinicians independent of specific specialty (i.e. knowledge of transgender-specific diagnostic criteria, mental health concerns, hormone prescribing, and primary care). Recognition that for non-binary persons tailoring of current protocols may be done within the context of accepted safety guidelines, using a multidisciplinary approach including mental health. Explicit suggestion that fertility preservation options need to be discussed in a timely fashion. Updated gender affirming hormone regimens, based upon recently published treatment protocols. Patient/PCP Mental Health Provider Medical model Endocrinology Specialist Surgeons other specialists 1

2 Presentation of Transgender Individuals Strategy: presentation in adulthood is common and late adolescence more the norm than the exception. Articulation? Awareness? Not known. Fertility is addressed in an ad hoc fashion. Strategy: December 11, 2011 Male hormones Female hormones Testosterone Estradiol Testosterone Estradiol Chan KJ, et al, 2018 Endocrine Practice Current Approach to Therapy Current Approach to Therapy Adolescents: GnRH agonists at Tanner 2 Adult Transmen: androgen supplementation can be lifelong. and discussion of transgender hormone Rx at earlier ages. 2

3 Current Approach to Therapy Adult Transwomen: blockade to some degree of androgen production or action along with some degree of estrogen supplementation thrombosis concerns. Case 1: 11 year old recorded male at birth I am a girl for many years Socially transitioned since kindergarten Supportive parents Female gender identity confirmed Exam Case 1: Case 1: Conundrum: Bone Density and Early Pubertal Youth Testes: Tanner 2-3 (Tanner 2) What would you do? Current Treatment Model Bone Mineral Density: 6 yr Follow-Up Potential study limitations: Relatively small N (34: 15 MTF, 19 FTM)? Relatively low hormone dosage during Rx No data on other factors influencing bone mass Dietary calcium intake Vitamin D levels Weight-bearing exercise Case 2: 55 year old with male external anatomy Lived as a man until 1 year ago But recent publicity has helped her recognize her life-long incongruence Denied hormone therapy: it is too dangerous Quadriplegic due to MVA DVT during hospitalization; Rx'd w/ warfarin Klink D et al. JCEM,

4 Case 2: Would you prescribe estrogen to this patient? What would be your reasoning? Case 2: A mainstay of transgender hormone treatment is estrogen for which there is a clear thrombosis risk for ethinyl estradiol and a likely risk for less thrombogenic 17 beta estradiol There has been at least one proposal for treatment with parallel prophylaxis when needed. Case 2: Asscheman et al. (2014) 1% incidence of VTE among 1076 transwomen (5.4 years) Gooren et al. (2008), no increase in VTE among 2236 transgender women on estradiol from 1975 to 2000 (Ethinyl estradiol = 6 8% incidence) Wierckx et al. (2013) 5% of 214 MTF individuals developed VTE within the first three years of estrogen therapy BUT 10 out of 11 of these women had at least one VTE risk factor (smoking, immobilization/ surgery, or thrombophilia) Endocrine Treatment of Gender Dysphoric/Gender Incongruent Persons: Endocrine Society Practice Guidelines Treatment safety Low DVT incidence with oral estradiol 1 recorded event among 676 trans women averaging 2 years of Rx with oral estradiol Case 3: 65 year old transgender man Has been living as a man for years on a stable testosterone therapy regimen (200 mg IM q 2 weeks). Recent pruritus and feeling flushed Hct 56% Arnold et al 2016 (JSM) 4

5 Case 3: What treatment related condition has he experienced? What changes do you recommend? Endocrine Treatment of Gender Dysphoric/Gender Incongruent Persons: Endocrine Society Practice Guidelines Case 3: Testosterone stimulates erythropoiesis. Androgen stimulated hct usually w/i normal range but polycythemia may be unmasked. Tobacco, sleep apnea should be addressed Hematological evaluation may be required Case 3: It is acceptable to mitigate high hematocrit with lower dose testosterone as long as levels are sufficient to maintain good bone health and to prevent menses. Case 4: 38 year old transgender man Has been living as a man for years on a stable testosterone therapy regimen for 18 years. He and his non-trans female partner of 1 year want to know their fertility options. Fertility in Transgender Men 54% desired children 38.5% would have considered oocyte/embryo cryopreservation Costs Donor sperm $500-1,000/vial Sperm cryopreservation $1,000-1,500 (with FDA testing) IVF $15,000/cycle Gestational carrier $50,000+ Wierckx, K. Human Reproduction,

6 Discussion What are this couple s options for fertility? Donor sperm Controlled ovarian hyperstimulation (IVF) with gestational carrier Long term androgen does not appear to deplete primordial follicle pool Extremely limited data on fertility preservation Endocrine Treatment of Gender Dysphoric/Gender Incongruent Persons: Endocrine Society Practice Guidelines Case 4: total male female One case series of 41 trans men s/p hysterectomy reported that endometrial tissue to be atrophic. There are no other published data. Prevalence and types of gender affirming surgery Endocrine Practice There are no published data demonstrating increased female repro tract CA risk in transgender men (4.7). Case 5 48 year old transgender woman with intermittent hormone use for the past four years presents for refills of medication Prescribed estradiol valerate 20 mg IM qo week, estradiol 2 mg PO daily Would like to maintain erectile function How would you manage this patient? 6

7 SUPRA-PHYSIOLOGIC levels which may expose individuals to harm without known benefit (e.g. erythrocytosis with testosterone and thrombosis risk with estrogen). SUPRA-PHYSIOLOGIC levels which may expose individuals to harm without known benefit (e.g. erythrocytosis with testosterone and thrombosis risk with estrogen). SUPRA-PHYSIOLOGIC levels which may expose individuals to harm without known benefit (e.g. erythrocytosis with testosterone and thrombosis risk with estrogen). SUPRA-PHYSIOLOGIC levels which may expose individuals to harm without known benefit (e.g. erythrocytosis with testosterone and thrombosis risk with estrogen). 7

8 21st Century Strategies: Transgender Hormone Care Joshua Safer, MD Center for Transgender Medicine and Surgery 8